Physician Perceptions of the Use of Medications for Attention Deficit Hyperactivity Disorder

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a prevalent mental health condition, occurring in 3% to 5% of school-aged children. Although stimulant medications are a recommended treatment for this disorder, physicians' views of these medications have not been systematically evaluated. OBJECTIVES: This study examined physician-prescriber perceptions of using medications to treat ADHD symptoms in children or adolescents. METHODS: A survey was developed with 4 physician expert in treating ADHD in children. The survey was pilot-tested with a sample of 10 practicing physicians. A sample of 1,000 physicians, with a history of prescribing stimulant medications to children or adolescents, was randomly selected and mailed a 30-item survey. Items were rated on a 7-point response scale (strongly agree, agree, slightly agree, undecided, slightly disagree, disagree, strongly disagree). RESULTS: A total of 365 physicians responded to the survey, for a 37% response rate. More than 92% of respondents strongly agreed or agreed that ADHD symptoms cause problems in pediatric patients and stimulants are effective in treating ADHD. The stimulant drug side effects of decreased appetite or weight loss, sleep disruption, and exacerbation of anxiety were a concern (strongly agree or agree response) for 32%, 50%, and 22% of physicians, respectively. Diversion of ADHD medication was a concern for 19% of respondents. Physicians reported that controlled medications for children or adolescents with ADHD are a burden for themselves (32% strongly agreed or agreed), for their staff (37% strongly agreed or agreed), and for parents (40% strongly agreed or agreed). Approximately 38% of physicians responded that they would prefer prescribing a nonstimulant medication with a U.S. Food and Drug Administration indication for treating children or adolescents instead of a stimulant medication, and 58% would prefer prescribing noncontrolled medication that does not have evidence of abuse potential versus one that is controlled and has evidence of abuse potential. CONCLUSIONS: Although physicians overwhelmingly perceive stimulant medications as being effective for treating ADHD symptoms in children or adolescents, many would prefer a nonstimulant medication. While many physicians consider the side effects of the stimulants easily managed, others are concerned about prescribing stimulants because of their side effects, risk of diversion, and administrative burden. The majority of physicians would prefer to prescribe a noncontrolled medication without abuse potential instead of a controlled medication to treat children or adolescents with ADHD.

RESULTS: A total of 365 physicians responded to the survey, for a 37% response rate. More than 92% of respondents strongly agreed or agreed that ADHD symptoms cause problems in pediatric patients and stimulants are effective in treating ADHD. The stimulant drug side effects of decreased appetite or weight loss, sleep disruption, and exacerbation of anxiety were a concern (strongly agree or agree response) for 32%, 50%, and 22% of physicians, respectively. Diversion of ADHD medication was a concern for 19% of respondents. Physicians reported that controlled medications for children or adolescents with ADHD are a burden for themselves (32% strongly agreed or agreed), for their staff (37% strongly agreed or agreed), and for parents (40% strongly agreed or agreed). Approximately 38% of physicians responded that they would prefer prescribing a nonstimulant medication with a U.S. Food and Drug Administration indication for treating children or adolescents instead of a stimulant medication, and 58% would prefer prescribing a noncontrolled medication that does not have evidence of abuse potential versus one that is controlled and has evidence of abuse potential.
CONCLUSION: Although physicians overwhelmingly perceive stimulant medications as being effective for treating ADHD symptoms in children or adolescents, many would prefer a nonstimulant medication. While many physicians consider the side effects of the stimulants easily managed, others are concerned about prescribing stimulants because of their side effects, risk of diversion, and administrative burden. The majority of physicians would prefer to prescribe a noncontrolled medication without abuse potential instead of a controlled medication to treat children or adolescents with ADHD. A The stimulants are controlled medications classified as Schedule II substances by the U.S. Drug Enforcement Administration (DEA). The Schedule II designation is assigned to substances with a high abuse potential and severe psychological or physical dependence liability. 12 Each state in the United Stares has its own laws on how Schedule II substances are to be dispensed. Prescribing Schedule II medications in California has more barriers than in any of the other states because California requires that physicians use a triplicate prescription for all Schedule II medications. The physician keeps one copy of the triplicate prescription, the original copy goes to the pharmacy, and the third copy is sent to the DEA. According to the California Bureau of Narcotic Enforcement, only 61% of physicians licensed in California are able to write prescriptions for Schedule II medications. 13 In a survey conducted by the Southern California Cancer Pain Initiative, 27% of physicians responded that they do not prescribe Schedule II medications because of fear of investigation, and 59% reported substituting a weaker opioid, despite the need for a Schedule II medication, to avoid regulatory scrutiny or investigation. 13 Previous research has examined physicians' knowledge and attitudes concerning diagnosis and treatment of ADHD 14 ; however, physicians' views concerning the medications for the treatment of ADHD have not been systematically evaluated. Because stimulants are being prescribed more frequently for children and adolescents, concerns have increased over their long-term effects and potential for abuse and diversion. 1 These concerns may impact physician prescribing practices of the stimulant medications for treatment of ADHD in children and adolescents. Furthermore, the controlled status of the stimulant medications (and resulting fear of investigation) may prevent physicians from prescribing these medications for children and adolescents with ADHD. The objective of this study was to examine physicians' perceptions regarding the use of medications to treat ADHD symptoms in children and adolescents with a focus on the perceived efficacy, side effects, abuse potential, and prescribing burden of the stimulant medications. Because prescribing preferences may vary according to physician specialty and state of practice (i.e., triplicate state versus nontriplicate state), the effects of these characteristics on physician perceptions were also evaluated.

ss Methods Physician Selection
This survey was a cross-sectional survey of physicians treating children and adolescents with ADHD in California, Arizona, Oregon, and Colorado. Using data obtained from a pharmacy claims system of a large managed care organization based in the Western United States, 1,000 physicians with a history of prescribing stimulant medications to children or adolescents between December 2001 and May 2002 were randomly selected to receive the survey. An equal number of surveys (n=500) were mailed to physicians in a triplicate state (i.e., California) and to physicians in 3 nontriplicate states (i.e., Arizona, Colorado, and Oregon).

Survey Description
In collaboration with 4 physicians expert in treating ADHD in children (i.e., 2 child psychiatrists, 1 pediatrician, and 1 adult psychiatrist), we developed a survey to measure physician perceptions on the use of medications for ADHD. The survey was pilot-tested with 10 practicing physicians to evaluate their comprehension of the items and response choices. Individual interviews were conducted with each of the 10 pretest physicians who focused on the interpretation of each item (e.g., "What does this question mean to you?"), the appropriateness of the response choices ("How well do the response choices capture your thought?"), and the overall content of the survey. This methodology was based on cognitive testing procedures described by Lessler and Forsyth. 15 Minor revisions to the survey were made based on results of the cognitive testing.
The final survey consisted of 30 items. The first 18 items asked physicians to select the response that most accurately described their opinion regarding a statement on the use of medications for ADHD (Table 2). Responses were rated on a 7-point scale: (1) strongly agree, (2) agree, (3) slightly agree, (4) undecided, (5) slightly disagree, (6) disagree, and (7) strongly disagree. Additional survey items asked for demographic information such as age, gender, years in practice, state of practice, practice setting, and medical specialty. Physicians were also asked to estimate the number of children and adolescents they see in their office in a typical week, the number with ADHD in a typical week, the amount of additional time it takes them to manage (e.g., writing, tracking) a controlled versus a noncontrolled prescription, and the additional amount of time it takes their staff to manage (e.g., working with parents, tracking) a controlled versus a noncontrolled prescription.
Each survey was coded with an identification number and mailed with a cover letter and stamped, self-addressed envelope for return mail. A medically related gift with a value of $25 was provided as compensation for completing the survey. A second mailing with a reminder letter and an additional physician survey instrument was sent to those who did not respond within 2 weeks of the initial mailing. Surveys were mailed during September 2002. Surveys received by September 27, 2002, were collected for data entry and analysis. Data were entered initially and then reentered through a verification system to ensure accuracy.

Statistical Methods
All statistical analyses were performed using SAS software, version 8.2. Means and standard deviations were used to describe continuous variables, and percentages were used to describe categorical variables. Survey responses were assigned a numerical value of 1 through 7, with 1 representing strongly agree and 7 representing strongly disagree. The mean survey response was Physician Perceptions of the Use of Medications for Attention Deficit Hyperactivity Disorder calculated for each question. F tests or t tests were performed to compare mean survey responses based on specialty and controlled prescription status (i.e., triplicate versus nontriplicate). In addition, the Dunnett-Hsu method was used to address the multiple group comparisons in physician specialty by comparing the mean survey response for child and adolescent psychiatrists to the mean survey response for each of the other specialties. ss

Results
Of the 1,000 physicians targeted for the survey, 365 (37%) responded after 2 mailings; 189 (52%) were from the triplicate state and 176 (48%) were from nontriplicate states. The demographics of the survey respondents were stratified by triplicate versus nontriplicate states ( Table 1). The distribution of age, gender, years in practice, and specialty were similar for physicians in triplicate versus nontriplicate states; however, the practice setting was significantly different for physicians in triplicate states compared to physicians in nontriplicate states (P<0.0001).
An analysis was conducted to examine whether there were any differences in demographics for the survey responders compared to survey nonresponders. Demographic information on the 635 nonresponders was obtained from the pharmacy

Physician Perceptions of the Use of Medications for Attention Deficit Hyperactivity Disorder
Demographics of Survey Respondents* Responses to Survey Items* 3.0 claims system; this information was not complete for all of the demographic characteristics. The pharmacy claims data for nonresponders were compared to the demographic information reported by the survey responders. There were no significant differences between responders and nonresponders when comparing physician age (based on data from 292 nonresponders), gender (based on data from 287 nonresponders), controlled prescription status (i.e., triplicate versus nontriplicate states, based on data from all 635 nonresponders), or state of practice (based on data from all 635 nonresponders). Compared to responders, specialty was significantly different for the 506 nonresponders with specialty data (P<0.0001). Responders were more likely to be psychiatrists (combining psychiatrists and child and adolescent psychiatrists; 21.6% versus 9.1%, respectively), and less likely to be family practice (12.7% versus 28.9%, respectively). However, these data are difficult to interpret because of the large amount of missing data for nonresponders in the pharmacy claims system. Physician responses by survey item are shown in Table 2. Approximately 97% of physicians strongly agreed or agreed that ADHD symptoms cause problems in school, and 96% strongly agreed or agreed that ADHD symptoms cause problems outside of school. Physicians overwhelmingly agreed that stimulant medications are effective in treating ADHD symptoms in children or adolescents both in school (97% strongly agreed or agreed) and outside of school (92% strongly agreed or agreed).
Stimulant side effects such as sleep disruption and decreased appetite or weight loss were a concern (with a strongly agree or agree response) for 32% and 50% of physicians, respectively. Approximately 22% of physicians strongly agreed or agreed that they were concerned that prescribing a stimulant for children or adolescents with ADHD and anxiety will exacerbate their anxiety. However, 37% of physicians strongly agreed or agreed that the side effects of stimulants are easily managed.
Physicians responded that controlled medications for pediatric patients with ADHD are a burden to themselves (32% strongly agreed or agreed), to their staff (37% strongly agreed or agreed), and to parents (40% strongly agreed or agreed). When they were asked to estimate the amount of additional time it takes them to manage (e.g., writing, tracking) a controlled versus a noncontrolled prescription, physicians reported an average of 6.0 ± 5.2 minutes per prescription. When asked to esti- mate the amount of additional time it takes their staff to manage (e.g., working with parents, tracking) a controlled versus noncontrolled prescription, physicians reported an average of 6.8 ± 6.2 minutes per prescription. Approximately 19% of physicians strongly agreed or agreed that they are concerned with diversion when they prescribe a controlled medication for children or adolescents with ADHD. Approximately 38% of physicians strongly agreed or agreed that they would prefer prescribing a nonstimulant instead of a stimulant if a nonstimulant with a U.S. Food and Drug Administration (FDA) indication for treating ADHD in children or adolescents was available. In addition, 58% of physicians strongly agreed or agreed that they would prefer prescribing a noncontrolled medication that does not have evidence of abuse potential versus one that is controlled and has evidence of abuse potential.

Preferences of Physicians According to Specialty
Physician responses varied according to specialty (Table 3). Child and adolescent psychiatrists were more likely than pediatricians and family practice physicians to agree that ADHD symptoms cause problems and that the stimulants are effective in treating ADHD (survey items 1 through 4 in Table 3). Compared to child and adolescent psychiatrists, family practice physicians and pediatricians were more likely to agree that controlled medications are a burden to themselves and to their staff, and psychiatrists and pediatricians were more likely to agree that controlled medications are a burden to parents (survey items 5 through 7 in Table 3).
Compared to other specialties, child and adolescent psychiatrists were more likely to disagree that drug holidays should be incorporated when prescribing stimulants to children and adolescents with ADHD (survey item 8 in Table 3). Child and adolescent psychiatrists were more concerned with the stimulant side effects of sleep disruption and decreased appetite/weight loss than family practice physicians (survey items 10 and 11 in Table 3); however, they were also more likely to agree that stimulant side effects are easily managed compared to pediatricians (survey item 13 in Table 3).
Child and adolescent psychiatrists were less likely than other specialists to be uncomfortable prescribing a stimulant for children and/or adolescents with ADHD (survey item 14 in Table  3). Family practice physicians were more likely than child and adolescent psychiatrists to prefer a noncontrolled medication that does not have evidence of abuse potential instead of one that is controlled and has evidence of abuse potential (survey item 18 in Table 3).

Perceptions of Physicians in Triplicate Versus Nontriplicate States
Several survey items had significantly different survey responses among physicians in triplicate states versus physicians in nontriplicate states (Table 4). Physicians in the triplicate state (California) were more likely than those in the nontriplicate states to believe that controlled medications for children or adolescents with ADHD are a burden to themselves (mean survey response of 3.7 versus 4.1, P=0.02). Physicians from the triplicate state reported that it takes them an average of 6.8 ± 5.3 additional minutes to manage a controlled prescription than a noncontrolled prescription, while physicians in nontriplicate states reported an average of 5.0 ± 5.1 additional minutes (P=0.001).
More physicians in triplicate states than in nontriplicate states thought that drug holidays should be incorporated when prescribing a stimulant for children or adolescents with ADHD (mean survey response of 3.7 versus 4.1, P=0.02). More physicians in triplicate states than in nontriplicate states were uncomfortable prescribing a stimulant for children or adolescents to treat ADHD (mean survey response 5.9 versus 6.4, P<0.001).

ss Discussion
This study was the first to systematically evaluate physicians' perceptions regarding the use of medications for the treatment of children and adolescents with ADHD. Since current clinical  practice guidelines 1,2,7,10,16 and clinical studies 3,17-19 support the use of the stimulant medications as an effective treatment of ADHD, it is not surprising that physicians believe that the stimulant medications are effective for treating ADHD symptoms in children and adolescents. However, the preferences of some physicians to prescribe a nonstimulant instead of a stimulant medication indicate that the effectiveness of the stimulant medications is not the only factor that physicians evaluate when prescribing a medication to treat ADHD in children and adolescents. Child and adolescent psychiatrists were more concerned with the stimulant side effects of sleep disruption and decreased appetite or weight loss than were family practice physicians, 50% to 32%, respectively. These results are not surprising considering that the stimulant side effects of insomnia and appetite suppression have been well documented in the literature. 10,17,20 Approximately 22% of physicians were also concerned that prescribing a stimulant for children and/or adolescents with ADHD and anxiety will exacerbate their anxiety. Despite concerns regarding the stimulant side effects, 37% of physicians responded that the side effects of the stimulants are easily managed. Physicians were more likely to believe that the side effects are easily managed if they were child and adolescent psychiatrists, which may indicate that physicians who have more experience in treating children and/or adolescents with ADHD are more confident in managing the stimulant side effects.
Approximately 19% of physicians were concerned with diversion when they prescribe a controlled medication for children or adolescents with ADHD. The concerns of these physicians corroborate those of the DEA, which has been supportive of a public education program to decrease the diversion of the stimulant medications. 10 Rates of diversion of the stimulant medications in the United States have not been documented in the literature; however, diversion rates were reported among adolescent students who were prescribed stimulants in Canada, where 14.7% gave away some of their medication, 7.3% sold some of their medication, 4.3% experienced theft, and 3.0% were forced to give up some of their medication. 21 With the recent increase in prescribing of stimulants for treatment of ADHD, additional studies are warranted to evaluate the occurrence of diversion of the stimulants among children and adolescents in the United States. 3 Prescribing burden was another concern of physicians, with 32% to 40% indicating that controlled medications are a burden to themselves, their staff, and parents. Physicians in triplicate states were more likely to think that controlled medications are a burden to themselves compared to physicians in nontriplicate states. This may be the result of the extra burden (e.g., paperwork and time) involved with writing a triplicate prescription. Compared to some of the other specialties, child and adolescent psychiatrists were less likely to think that controlled medications are a burden to themselves, their staff, or parents. One possible explanation for this is that child and adolescent psychiatrists may treat the most severe cases of ADHD, in which case, they and the parents may be more likely to appreciate the symptom control from the stimulant medications and less likely to be concerned with the burden of administering a controlled medication.
Until recently, for patients who were unable to tolerate a stimulant medication, physicians had to resort to the antidepressants (e.g., tricyclics, bupropion), antipsychotics, clonidine, and guanfacine. 19,[22][23][24] While these medications have been studied in small populations of patients with ADHD, there have been mixed results, and none have been FDA-approved for ADHD or for use in children and/or adolescents. Atomoxetine (Strattera), which was approved by the FDA in November 2002, is the first noncontrolled, nonstimulant medication that is FDAapproved for the treatment of ADHD in children, adolescents, and adults. 25 Since this survey was conducted prior to the availability of atomoxetine, it would be interesting to conduct a similar survey of physician preferences now that physicians have clinical experience using this new chemical entity.

ss Limitations
There were several limitations that may prohibit generalizing these results to other populations. Since physicians who prescribe stimulants to children and adolescents were selected for this survey, these results may not be representative of all physicians who treat children and adolescents with ADHD. This study only included physicians practicing in 4 states in the Western United States; therefore, geographic differences in physician preferences must be noted when extrapolating the results of this survey to other regions of the country.
While the 37% response rate is consistent with other physician response rates for studies pertaining to ADHD, 14 the 63% of physicians who did not respond could have different characteristics and different responses to the survey items than the physicians who returned the surveys. The survey asked respondents about their perceptions of the stimulants as a class of medications and did not distinguish among the different stimulant products (i.e., methylphenidate, dextroamphetamine, and amphetamine). Physicians may consider the side effects, abuse potential, and efficacy of one specific stimulant medication different from another. Furthermore, the survey asked about prescribing preferences for both children and adolescents combined and did not allow physicians to indicate if they had differing thoughts about medication prescribing for children versus adolescents.

ss Conclusion
Physicians overwhelmingly perceive stimulant medications to be effective for treating ADHD symptoms in children or adolescents, but many would prefer to prescribe a nonstimulant medication. Even though some physicians consider the side effects of the stimulants easily managed, others are concerned about prescribing stimulants because of their side effects, risk of diversion, or administrative burden. The majority (58%) would prefer to prescribe a noncontrolled medication without abuse